Registered Nurse (RN) Utilization Review
Demonstrates fiscal responsibility related to patient needs, resource utilization, payer requirements and organizational goals. Screens patients for admission criteria (medical necessity/patient status/level of care) utilizing InterQual® criteria and documenting the review in the CERME® software system. Conducts reviews as established by CMS guidelines and Utilization Management processes. Secures authorization/certification for services by communicating necessary and requested information with payors. Communicates information that will impact the discharge plan to the Transitional Care Coordinator and Case Managers to ensure high quality care coordination.
Conducts admission, continued stay, outlier, readmit reviews as assigned and per utilization management processes.
Determines appropriate level of care according to InterQual® criteria and other national guidelines, and facilitate movement of patients in a timely manner.
Ensures physician level of care orders are authenticated as necessary.
Determines patient needs and resources through clinical assessments from point of entry to hospital and assists in the discharge planning communication as appropriate.
Reports malfunctions with equipment, applications, EMR, etc. & obtains assistance as indicated.
Refers cases appropriately to Physician Advisor, obtains second level determination and ensures appropriate documentation is present in the medical record.
Obtains required authorization/certification and ensures appropriate documentation is present in the medical record.
Maintains confidentiality of all patient information following our HIPPA guidelines.
Discusses patient status and care with physician team and nursing staff as appropriate. Collaborate with staff, physicians, care/service coordinators, payers, patients, and their families to coordinate and provide the level of care necessary to meet member’s health need.
Utilizes the CERME® software system to document reviews, assessments and progress notes. Documents case status in Epic as appropriate. Documents the necessary process for utilization of Condition Code 44 to ensure appropriate patient/patient representative notification and billing.
Helps others understand issues and differences that impact the plan of care.
Provides communication to case management team members, nursing, and medical staff providers.
Reports any concerns regarding coordination of patient care to the appropriate personnel/process (e.g. Manager, Director, Peer Review, RL®).
Able to manage assignments, if workload is increased, prioritizes so vital activities are accomplished.
Facilities multi-disciplinary teams approach when organizing the coordination of care or resources.
Serves on departmental/hospital team or committee when asked to do so.
Attends all other assigned committee/task force meetings unless excused by Director or Manager.
Assumes responsibility for understanding the posted "hard" copies & electronic departmental agency minutes/memos.
Participates in meetings by taking part in discussions, contributing ideas based on TMC’s best interest rather than own self-interest, volunteering to take on responsibilities, problem solving, facilitating reaching a consensus & fulfilling assigned responsibilities by the deadline.
Participates in performance improvement data collection and/or problem resolution when assigned.
Practices cost-effectiveness with judicious use of supplies, equipment and resources.
Shares information from in-services/workshops/seminars/conferences with departmental team.
Follows and maintains compliance with regulatory agency requirements.
Acts as an education resource to the clinical community and organizational leadership with regards to local, state and federal compliance issues.
Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
Performs related duties as assigned.
EDUCATION: Graduation from a qualified, nationally-accredited nursing program required. Bachelor’s degree preferred.
EXPERIENCE: Three (3) years RN nursing experience, preferably in an acute care setting. Three (3) years experience working in a case management or utilization review role preferred.
LICENSURE OR CERTIFICATION: Active unrestricted RN license within the State of Arizona, or NLC.